AACVPR Cardiac Rehabilitation A Lesson in Patience and Success Founded in 1985, the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) is dedicated to the professional development of its members, through information, networking, and educational opportunities. Central to the mission is the improvement in the quality of life for patients and their families. Anne M. Gavic, MPA, FAACVPR AACVPR The mission statement of the American Association of Cardiovascular and Pulmonary Rehabilitation is: To reduce morbidity, mortality, and disability from cardiovascular and pulmonary diseases through education, prevention, rehabilitation, research, and aggressive disease management. 3000 members AACVPR Leadership 12 member person BOD President Jody Hereford, BSN, MS President Elect, Larry Hamm, PhD Immediate Past President, Margorie Kind, MD 10 member Scientific Advisory Council (SAC) Multidisciplinary council: RD, Psych, Cardiac RN, Ex Phys, Cardiologist, PT RT, Pulmonologist, Pulmonary RN 22 Committees (incl Prog Cert and Recert) 39 State and regional affiliates AACVPR Key Initiatives Professional Education Utilization of CR (Referral Enhancement Task Force) Legislation and Reimbursement Disease Management / JCAHO Disease Specific Care Alternative Delivery Methods (Program Cert / Recert Task Force) Professionalization of Ex Phys (Ex Phys Task Force) Enhancing Professional Liaisons (International Liaison subgrp) AACVPR Position papers: Scientific Evidence of the Value of CR Services with Emphasis on Patients Following Myocardial Infarction Efficacy of Risk Factor Intervention and Psychosocial Aspects of CR Scientific Basis of PR Outcomes evaluation in CR/ secondary prevention programs: improving patient care and program effectiveness. AACVPR Consensus Statement AACVPR Position Paper: Medical Director Responsibilities for Outpatient CR / Secondary Prevention Programs JCR 2005:25;315-320
The Vision for 1995 - AACVPR Board Initiative to Investigate the Process Driven by membership Concern regarding standardization and quality State experience - North Carolina model Survey of affiliate members Clinical Practice Guidelines for Cardiac Rehabilitation 1995 Method to determine compliance with guidelines AACVPR Board decision to explore the feasibility of a certification process - Task Force development to determine process and content Task Force organized to: Define Determine feasibility of process Look at process and content Recommend basis of certification Goals What do we hope to accomplish through program certification? Benefits What are the benefits to our members and the organization? Process What will the process look like? What is Process to evaluate compliance with essential standards and guidelines Later: Collection of Outcomes data to determine big picture benefit of CR in clinical practice Feasibility National vs State Cardiac vs Pulmonary Variability in delivery of services Determine foundation of services Legal issues Decision: State involvement with national oversite Certification granted by national Initiative to Develop Process Basis - Grounded in Research and Guidelines AACVPR Guidelines for CR AACVPR Core Competencies for CR Professionals Clinical Practice Guidelines for Cardiac Rehabilitation and Secondary Prevention ACSM Guidelines for Graded Exercise Testing and Prescription ACSM Resource Manual for Guidelines for Exercise Testing and Prescription More recently added: AACVPR Consensus Statement: Outcomes Evaluation in CR/ Secondary Prevention Programs JCR March / April 2004:24(2) 68-79 AACVPR CR Resource Manual AACVPR Position Paper: Medical Director Responsibilities for Outpatient CR / Secondary Prevention Programs JCR 2005:25;315-320 Research and Evidence base Program Guidelines
Goals of Align programs with evidence- based medicine and standards of care Improve clinical practice and quality of care Promote standard outcome measurements Advance the Multidisciplinary process Favorably influence reimbursement Benefits of For the program: Benchmark against evidence and standards Standardization of practice Establish best practice programming Evidence of of CR staff competency Potential for reimbursement connection For the Organization: Identification of best-practices as model Collection of aggregate outcomes data to support program efficacy The Review Process Voluntary Membership not required Program operational 1 year Each separate facility must apply individually Peer Review 2-Tiered Review Affiliate Support and Involvement National Oversite Onsite Review Option Certification Granted by Board of Directors Appeals Process Valid for 3 years Abbreviated re-certification process Ready Set Go 1994-5 - Membership inquiry and BOD decision 1995 - Task force work to develop process and application 1999 - First round of applications - certification (task force served as first review committee) 2002 - First round of re-certifiction Application and Review Calendar Sept 1 - Applications available to programs (available on AACVPR website) Sept 1-Dec 1 - Applications submitted (4 copies) Dec 12-14 - Applications sent to State / Regional chairs Dec 18-Mar 16 - State / Regional committees review Mar 23- April 13 - Applications prepared for National Program Cert Committee review April 20-22 - National Review of all applications May 1-11 - Letters sent requesting additional information May 18 - June 22 - Requested information submitted July 5-11 - Preparation for second review July 13-15 - Final review by National Committee Early August - Information and recommendations prepared for BOD approval August - BOD reviews and approves recommendations from committee August 31 - Programs notified of final review recommendation and certificates distributed Key Areas of Emphasis Safety Quality Multi-disciplined Multi-faceted Outcomes
The Application Program Demographics Program Management Personnel Staff Records Facilities / Equipment Documentation Policies / Procedures Medical Records Medical Emergencies Outcomes and Assessment Patient Care Assessment Therapeutic Plan Interventions / Treatment Components Evaluation / Discharge / Follow up Supporting Documentation Program Demographics Program Management Personnel Staff Records Staff Competency Skill Review Facilities / Equipment Emergency Equipment and Supplies Documentation Policies / Procedures Policies and Procedures Staff Meetings Medical Records Physician Referral Informed Consent Exercise Prescription Medical Emergencies Medical Emergencies Emergency Equipment Medical Emergency Inservices Untoward Events Outcomes Assessment Outcomes Measures Patient Care Assessment Risk Stratification Psychosocial Assessment Nutritional Assessment Educational Assessment Therapeutic Plan Individualized Care Plan Interventions / Treatment Components Educational Sessions Evaluation / Discharge / Follow up Feedback to Physicians The Application Supporting documentation Staff Competency Skill Review Medical Emergency Inservices Emergency Equipment and Supplies Untoward Events Policies and Procedures Outcomes Assessment Staff Meetings Risk Stratification Physician Referral Psychosocial Assessment Informed Consent Nutritional Assessment Exercise Prescription Educational Assessment Medical Emergencies Individualized Care Plan Emergency Equipment Educational Sessions Feedback to Physicians Details Details.. Binders, tabs and tables HIPPA Yes / No = 85% Reasonable alternative Supporting narrative Indicates required documentation for re-certification Staff Competency Skills Review All staff participate in yearly skills competency review check-off Narrative and required table format of the checklist for all competencies assessed for all staff Emergency Equipment and Supplies Attach a list of all equipment and supplies that may be needed in case of a medical emergency Include a completed competency tool
Written Policies/Procedures are up to date and are Implemented by the Staff Written policies and procedures are up to date and have been reviewed within the past year Attach the cover sheet / Signature Page which indicates policies and procedures have been reviewed by the medical director, manager / director within the year. Attach the Table of Contents of Policy and Procedure Manual that relate directly to CR Staff Meetings, Minutes and Attendance Lists ( Min 4/yr) Program services are directed, integrated and coordinated as evidenced by routine staff meetings, minutes and attendance lists Attach the Minutes, dates and Attendance List from the Last 4 Staff Meetings Evidence of Signed Physician Referral / Order Attach a Completed and signed referral form used by your department ( all patient identifiers must be blanked out) If a computerized or general hospital form is used - include a brief narrative and /or policy describing its use. Informed Consent Attach a Completed and signed Informed Consent Form with all patient identifiers blanked out Informed consent to include: Explanation of program Potential Risks Expected Benefits Confidentiality Patient / witness signature Exercise Prescription Approved By Medical Staff Attach a completed copy of an exercise prescription form. Provide the policies explaining the exercise prescription process, including Mode Frequency Duration Intensity Progression Policies must show evidence of physician review Exercise Prescription Acceptable Alternative Policy and Procedure or standing orders signed by physician indicating how exercise prescription is formed Unacceptable Form or policy showing only determination of exercise intensity (Target HR) Intensity targets not within AACVPR or ACSM standards Statement of progress as tolerated with no criteria for progression No physician signature on form or policy Incomplete form No narrative
Medical Emergencies Medical Emergency Plan flexible enough to handle all possible emergencies Submit a copy of all written policies that address specifically what is done for each of the following emergencies: Emergency Equipment Documentation Department verification of operational readiness of emergency equipment for 3 months Cardiopulmonary Arrest Angina Acute Dyspnea Tachycardia Bradycardia Hypertension Hypotension Hyperglycemia Hypoglycemia Attach a checklist from the last three months verification of operational readiness of emergency equipment (signed and dated) Medical Emergency Inservices Minimum 4/year Attach the minutes, attendance, and topics covered from the last 4 emergency inservices May include: Mock codes Crash cart review / defibrillator use Review of actual code CPR / ACLS if given as a department Emergencies must be specific to CR Untoward Events Acceptable: Log which includes type of event, date, patient (identifiers blocked) Results from a patient chart review indicating # of charts, # of events, type fo events, Notes from patient charts indicating an event and follow up Unacceptable: No indication of untoward events in 3 month period Committee may request additional information if none are indicated Outcomes Evidence of ongoing patient and program outcome measurements are collected to evaluate the program s general effectiveness and efficacy from each of 4 domains Outcomes Measurement and Reporting For each outcome category: Clinical - Functional Capacity, Lipids, METS, Weight, BP Behavioral - Smoking Cessation, Adherence with Diet or Exercise, Stress Management Health - Quality of Life, Loss of Work Days Service - Patient Satisfaction, Access and Utilization of Service, Financial and Economic
OUTCOMES Narrative for each domain, including tools utilized and conclusions drawn from data Table to include: Number of patients included (must be 30) Pre program data Post program data Change between pre and post measures (% change, units of change or change toward goal) Cumulative data only Risk Stratification Risk Stratification is Utilized to Determine Appropriate Level of Care and Monitoring Provide brief narrative describing the method of risk stratification and how it influences development and implementation of the plan of care. i.e., level of supervision/ monitoring, number of visits, rate of exercise progression, etc Psychosocial Assessment Submit a completed copy of the tool or method utilized and a brief narrative of the process used to determine need for intervention, follow up and integration into the plan of care. Psychosocial Assessment Acceptable Standard Validated psychosocial assessment, administered and scored by a psychosocial professional - submit completed copy of tool Structured interview by CR staff or psychosocial professional - with standardized questions and criteria for referral to a psychosocial professional Notes from interview by psychosocial professional Nutritional Assessment Submit a completed copy of the tool or method used and a brief narrative of the process used to determine need for intervention, follow up and integration in to plan of care Nutritional Assessment Acceptable: Include tool used for assessment, scoring and what determines need for referral and follow up Diet History reviewed by RD Standardized questions or notes from dietary evaluation Describe who reviews the dietary evaluations Indicate who conducts the dietary consultations - show evidence of RD availability -may be on call
Educational Assessment Educational assessment of patient / family s needs Submit a completed copy of the tool or method utilized, a brief narrative of the process to assess and meet patient s and family s educational needs May include: Standardized educational / knowledge evaluation Checklist of education topics given to patient and family Narrative indicating education is based on individual need Written Individualized Care Plan Written individualized plan of care and projected outcomes/ goals are developed fpr each patient (incl. education, exercise, psychosocial and nutrition) Attach a completed plan of care and narrative describing Assessment, Goals, Intervention, Evaluation, Follow up Include Education, Exercise, Psychosocial, and Nutrition domains Education Sessions Educational sessions (individual or group) are provided for all patients Attach a list of the educational sessions offered over the past 3 months, including dates. Include all opportunities available If individual teaching is done, include a narrative describing resources available, when the teaching is done and who provides it. Feedback Provided to Physicians on a Regular Basis Submit a completed form and provide a written narrative explaining procedure for physician feedback. Information regarding exercise, clinical, and risk factor modification must be included. Successes Widespread acceptance from membership Engaging Affiliates in review process / oversite committee Education of members At annual meeting cert and recert sessionn Best practice workshops Affiliate education Website information Program quality improvement and standardization Number of programs certified (1313)/ recertified Evolution of the process and application?? Link with payment Challenges Initial Skepticism Cost national vs affiliate Interpretation of standards Amount of subjectivity Peer review No onsite survey Process of Education and Mentoring vs Punative Appeals process
Future Direction Process guided by the BOD Review committee separate from quality improvement task force Objective measures - weighted scoring Provisional status Driven by Evidence Based Medicine and Guidelines and Performance Measures - directly linked with documents endorsed by AACVPR Use aggregate data for registry project Online application and review process Closely linked with outcomes, guidelines and document oversite committees Move from a narrower more procedure oriented to broader process, quality improvement and evidence based model Ongoing evolution of the process and application Research and Evidence base Performance Measures Program Guidelines Research and Evidence base Performance Measures Program Guidelines THANK YOU!! www.aacvpr.org certification